Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0200X | Radiology | 1031 | SD |
Y | 213ER0200X | Radiology | 1031 | SD |
NPI | 1346317807 |
---|---|
Provider Name | Dr. Benjamin Axel Simonson |
First Address | Brandon, SD 57005-1679 |
Second Address | Brandon, SD 57005-1679 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/11/2006 |
Last Update Date | 14/04/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U94987 | (02) | SD |